Complex Needs

Many Customers that we support have complex health, as well as social care, needs. To ensure a holistic approach is taken when planning and delivering support, we work in co-operative partnership with other community-based professionals, including community and hospital-based Social Work teams, District Nursing teams, community-based medical and healthcare services, hospitals, hospices and General Practitioners. This ensures that each Customer’s identified needs and outcomes can be met across the health and social care spectrum by appropriately involved qualified professionals.

Prior to commencement of each new care package, we work with the Customer to identify and record their specific conditions and any particular needs and preferences as to how they would wish us to support them with these. On referral, the Customer’s conditions are recorded on our Customer Diagnosis Matrix to ensure that we are aware of each Customer’s medical condition and history. This informtion feeds into our Work Force Training and Development Plan. Training is then arranged for all staff to meet the identified needs of our Customers through the Diagnosis Matrix. This ensures our Customers’ needs are appropriately met.

People with such complex health and social care needs include those with:

• Cancer
• Cerebral Palsy
• Dementia
• Head Injury
• Heart Disease
• Huntington’s Disease
• Kidney Disease
• M E (Chronic Fatigue Syndrome)
• Motor Neurone Disease
• Multiple Sclerosis
• Muscular Dystrophy
• Parkinson’s Disease
• Renal Failure
• Spinal Injury
• Stroke

Many Customers using our service may have a combination of complex needs associated with their condition. For example a person who has had a dense stroke may have mobility difficulties and require the assistance of two members of staff using appropriately assessed equipment for all transfers throughout the day. They may require assistance with all aspects of intimate personal care including assistance with continence management, personal care – dressing and undressing. They may also have communication difficulties and may require special dietary guidelines, issued to us by the Speech and Language Therapist due to swallowing difficulties.

Their person-centred, outcome-based support plan to meet their complex needs is prepared. This may include allocating a small team of highly skilled and experienced staff to this Customer, and assigning two staff from the team to visit four times per day or as needed.

End of Life Care

Advances in medical technology, research and treatment mean that many more people are living longer, and will need palliative/end of life care. The majority of people do not want to die in hospital, and a significant number of those offered a choice, would prefer to die at home where possible. For people who have chosen to remain at home we work in conjunction with District Nurses, General Practitioners, Macmillan and Marie Curie Nurses, and liaise with the local hospitals to ensure Customers receive holistic support at the end of life. Our staff receive specialist training to ensure that they work in conjunction with other community based professionals to support people to achieve the best quality of life at their end of life, with dignity, in the place of their choice.

Reablement / Convalescent Support

We can provide a gradually reducing support package to those returning home from hospital or recovering from an injury, illness or accident where intensive support is required in the initial stages. We work with Customers to regain their independence in all aspects of their daily life and as they do so, the care package can be reduced until it is no longer required.

Child Support Services

We have been working with families to assist them to support their children at home in a variety of ways since 1992. The type of support we can provide varies enormously depending on the individual needs of the children and their family / guardians. For example:

• We provide short term support for new mothers on their return home from hospital.
• We support a parents/guardians to care for children with such complex conditions as cerebral palsy, autism, spina bifida and cancer.